Rising cases of cholera in Ethiopia: a need for sustainable wash practices?
Authors: Mubarick N. Asumah, Bijaya K. Padhi, Abhinav Sinha
Journal: International Journal of Surgery (2023)

Cholera is often referred to as an acute diarrheal disease triggered by the ingestion of food or water polluted by Vibrio cholerae. This consequently ends with severe dehydration and sometimes leads to death. Since the emergence of cholera in 1817, there have been seven cholera pandemics, with the most recent being in 1961 in South Asia, reaching Africa and America in 1971 and 1991, respectively1. This has reached almost all parts of the world, with Africa and Asia recording nearly all the reported cases in recent times. Public health continues to be threatened by cholera, which also serves as a sign of inequality and a lack of social progress. According to the WHO, drinking water or eating food infected with V. cholerae leads to severe acute watery diarrhea that could last from 12 hours to 5 days. Although a higher proportion of people may get infected, most infected people do not show any signs of their illness. Thus, the incidence of cholera across the world is underestimated due to issues including inadequate reporting, insufficient epidemiological monitoring, and a lack of laboratory capability2. However, available literature suggests that there are about 21 000–143 000 yearly fatalities from cholera, with an estimated worldwide burden of 1.3–4.0 million new cases annually3. Ninety-nine percent of all cholera cases globally are found in South Asia and Africa alone. The largest disease incidence seen in these regions is connected to the poorer infrastructure for water, sanitation, and hygiene (WASH) in these nations, and the presence of the disease is strongly correlated with the deprivation of safe water for drinking, inadequate hygiene practices, and low socioeconomic status4. Cholera outbreaks have survived and thrived with the severe acute respiratory syndrome coronavirus-2 pandemic since its emergence in 2020. According to the WHO, cholera cases declined in 2020. For instance, in 2020, 323 320 cholera cases were reported in 80 countries, with 857 lives lost in 27 countries. This represents a 65% decrease from 2019, when there were reports of 923 037 cases and 1911 deaths worldwide. There are several reasons to describe this occurrence. In nations where cholera is widespread, the coronavirus disease 2019 (COVID-19) epidemic has also raised pressure on the country's current health services5. Given that COVID-19 monitoring and pandemic containment measurements were given priority, it is quite possible that the public health surveillance system and diagnostics capacity for cholera detection and reporting may have been stretched to the limit. During the COVID-19 epidemic, social isolation, the promotion of good hygiene practices, and even lockdown measures in certain nations could have had an effect on the patterns of cholera transmission6. However, Ethiopia has recorded cholera outbreaks throughout 2019–2021, despite the general decline in the number of cholera cases reported during the first year of the COVID-19 pandemic in 20207. The Ethiopian authorities have implemented steps for cholera outbreak investigation and containment, including the establishment of designated facilities for the treatment of cholera cases. Also, they have requested the Oral Cholera Vaccine (OCV) International Coordinating Group (ICG) of the WHO for the emergency use of OCVs in 2019. In addition, the Ethiopian government has used the bilateral diplomatic channel to request OCV doses from the Republic of Korea in order to support large-scale reactive mass vaccination campaigns to control cholera outbreaks6–8. More recently, the Ethiopian government has created a thorough multisectoral national cholera control plan and formally stated its commitment to a roadmap for national cholera elimination. The 'Multisectorial Cholera Elimination Plan, Ethiopia 2021–2028' was approved in 2021 and is geared towards achieving the end of cholera by 2030 as part of the Global Roadmap8. Despite these efforts by the Ethiopian government, four stool specimens cultured for Vibrio cholera presented the first confirmed cases of cholera, which were reported to the WHO Ethiopian National Director on 14 September 2022. Given that most people with cholera are asymptomatic, it is possible that the reported cases are just the tip of the iceberg and the true figures are under-reported. By 25 October 2022, about 273 cholera cases with nine deaths had been reported. Although investigations are ongoing on suspected incidents in East Bale, about 114 more woredas (a district of Ethiopia) are potentially at risk of an epidemic. Since 10 October 2022, there has been a 30% rise in the caseload, with new cases being recorded every day in the Berbere and Kersadula woredas9. According to the Ethiopian Public Health Institute, nearly 459 000 people, mostly internally displaced persons residing in camps, are at high risk in the four woredas. The absence of collaborators and limited financing impede the response9. Nonetheless, the cases have been on the rise, with 491 confirmed cholera cases documented as 23 November 2022, with 20 mortalities. In the six woredas, over 555 000 individuals are at higher risk. With new cases being reported every day in the Berbere, Guradamole, and Quarsadula woredas, the caseload of afflicted persons has climbed by 28% in the previous 2 weeks. Cases are also growing quickly in Guradamole woreda in the Liban zone, particularly at internally displaced person unstructured sites where more than 60% of the new afflicted caseloads are documented. Restricted finance and the presence of limited partners impede the response10. A total of 47 samples from the most used water sources by a WHO WASH expert; 21 of the samples tested positive for fecal coliform (water contaminated with feces). To offer patients first-level care, the team operationalized and supported five oral rehydration sites. In addition to conducting water quality tests and supporting clean water stations, WHO delivered preventive hygiene kits to the local population and healthcare organizations11. Also, the triage, observation room, and recovery room were all put up under tents by the case management team. In addition to water availability, procedures for accessing health infrastructure and care capacities were built. The team has boosted its efforts while bolstering its capabilities and putting in place a cholera response that emphasizes infection control and treatment9,11. Despite these efforts, the main gaps include a lack of WASH treatment chemicals, a lack of water storage containers (such as reservoir tanks and jerry cans), a lack of water transportation capacity, and a high number of ineffective water systems. To control cholera and lower mortality rates in Ethiopia, a diversified strategy is essential. First, oral cholera vaccinations should be employed in all aspects of the country, with a focus on endemic areas. Also, implementing customized long-term sustainable WASH measures will guarantee the use of safe water, and good hygiene practices in cholera-endemic areas such as the refugee camps in Ethiopia. For those who have already been infected, treatment should be given while engaging the community to improve hygiene practices. Ethical approval and informed consent Ethical approval and informed consent were not required for this study. Sources of funding There was no source of funding for this research. Author contributions M.N.A., B.K.P., and A.S.: conceptualization. M.N.A. and B.K.P.: validation. M.N.A. and A.S.: resources. M.N.A.: writing – original draft preparation. B.K.P. and A.S.: writing – review and editing. A.S., B.K.P., and M.N.A.: visualization. B.K.P.: supervision. All authors have read and agreed to the published version of the manuscript. Conflicts of interest disclosure Author disclosure of potential conflicts of interest was done and none was reported. Guarantor Mubarick Nungbaso Asumah: Department of Global and International Health, School of Public Health, University for Development Studies, P.O. Box TL1350, Tamale Northern Region, Ghana and Ghana Health Service, Kintampo Municipal Hospital, P.O. Box 192, Kintampo, Bono East Region, Ghana. Bijaya Kumar Padhi: Department of Community Medicine and School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India. Abhinav Sinha: ICMR-Regional Medical Research Centre, Bhubanewar 751023, Odisha, India Data availability Data sharing is not applicable to this article as no new data were created.